Villa Manor Care Center
7950 W Mississippi Ave, Lakewood, CO 80226 · For profit - Corporation · 110 certified beds · (303) 986-4511 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- about 19% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.0% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.2% | 4.7% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.6% | 1.4% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 9.7% | 8.8% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.2% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 6.2% | 13.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 6.6% | 11.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 92.9% | 94.7% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.0% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 36.2% | 21.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.8% | 20.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.6% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 83.3% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 20.5% | 20.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.1% | 12.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.12 | 1.38 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.98 | 1.74 | 1.80 | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
56.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 147 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 86.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 44 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.45 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 30% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 56.2%CMS range 49.4–62.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 7.1–13.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 86.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 86.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 70.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 96.2% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.3%CMS range 2.6–9.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.17 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 110 beds and averages 78.9 residents a day — about 72% occupied, or roughly 31 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.17 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.10 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.72 hrs/resident/day on weekends vs 4.36 on weekdays — 15% thinner on weekends. RN hours go from 1.16 to 0.95 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · F2026-03-26 · tag F0887 — widespreadEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop and implement policies and procedures related to immunizations for five (#4, #6, #12, #38 and #58) of five residents reviewed for immunizations out of 37 sample residents.Specifically, the facility failed to:-Ensure the residents medical records indicated the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; and,-Ensure the residents medical records documented if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Findings include:I. Professional referenceAccording to the Centers for Disease Control's (CDC) Staying Up to Date with COVID-19 Vaccines, updated 11/19/25, retrieved on3/30/26 from https://www.cdc.gov/covid/vaccines/stay-up-to-date.html, read in pertinent part, Getting the 2025-2026 COVID-19 vaccine is important because:-Protection from the COVID-19 vaccine decreases with time;-Immunity after COVID-19…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-03-26 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment for residents and to help prevent the development and transmission of communicable diseases and infections for two of three units. Specifically, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) while providing care to residents who were on enhanced barrier precautions (EBP). Findings include: I. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 3/30/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent parts, Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-26 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for one (#70) of five residents out of 37 sample residents reviewed for respect and dignity.Specifically, the facility failed to ensure Resident #70 was covered appropriately during transport through the facility hallway. Findings include:I. Resident #70A. Resident statusResident #70, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included quadriplegia (paralysis of all four limbs and a torso caused by a spinal cord injury), diabetes type two, muscle weakness, contractures of the upper left and right arm, major depressive disorder and anxiety.The 2/17/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-26 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#85) of five residents reviewed for abuse out of 13 sample residents.Specifically, facility staff failed to report an allegation of abuse by Resident #85 towards Resident #79 to the facility's abuse coordinator and the State Agency. Findings include:I. Facility policy and procedureThe Abuse-Inservice Training policy, reviewed 6/17/24, was provided by the nursing home administrator (NHA) on 3/23/26 at 9:42 a.m. It read in pertinent part, The facility will maintain an effective training program for all staff, which included, at a minimum, training on abuse, neglect, exploitation of resident property, and dementia management, that is appropriate and effective, as determined by staff need and the facility assessment. Facilities must also provide training to their staff that at a minimum educates staff on procedures for reporting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for two (#4 and #58) of three residents reviewed for accidents out of 36 sample residents.Specifically, the facility failed to ensure Resident #4 and Resident #58's fall interventions were consistently implemented. Findings include: I. Resident #4 A. Resident status Resident #4, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included muscle weakness, dementia, respiratory failure, muscle weakness, and a history of falling. The12/23/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of five out of 15. The resident required substantial to maximum assistance with chair-to-chair transfers, toileting hygiene, and lower body dressing. The MDS assessment indicated Resident #4 had a recent fall at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure staff provided respiratory care consistent with professional standards of practice for two (#4 and #1) of four residents reviewed for oxygen services out of 37 sample residents. Specifically, the facility failed to ensure staff administered oxygen to Resident #4 and Resident #1 per physician's order. Findings include: I. Professional reference According to Nursing Skills, Open Resources for Nursing (Open RN); Ernstmeyer K, [NAME] E, editors. Eau [NAME] (WI): [NAME] Valley Technical College; published 2021, accessed on 3/31/26 from https://www.ncbi.nlm.nih.gov/books/NBK593208/, Oxygen is considered a medication and, therefore, requires a prescription and continuous monitoring by the nurse to ensure its safe and effective use. (Chapter 11) Manage oxygen therapy and equipment: If the patient is already on supplemental oxygen, ensure the equipment is turned on, set at the required flow rate, correctly positioned on the patient, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-26 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to remove medications and biologicals that were stored and labeled properly according to professional standards in two of five medication carts.Specifically, the facility failed to ensure expired medications were removed from the medication cart and disposed of. Findings include:I. Facility policy and procedureThe Storage of Medication policy, revised 6/30/25, was received from the nursing home administrator on 3/25/26 at 6:39 p.m. It revealed in pertinent part, The facility should ensure that only authorized facility staff, as defined by the facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medications in compliance with applicable law. The facility should ensure medications and biologicals were stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-19 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (#1, #2 and #3) of four residents reviewed for bathing out of four sample residents. Specifically, the facility failed to ensure Resident #1, Resident #2 and Resident #3, who were dependent on staff for bathing, received their scheduled showers. Cross-reference F725: failure to have adequate nurse staffing. Findings include: I. Facility policy and procedure The Activities Of Daily Living (ADLs) policy, revised 2/12/24, was provided by the nursing home administrator (NHA) on 3/19/25 at 2:21 p.m. It read in pertinent part, The resident will receive assistance as needed to complete ADLs. A resident who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene. II. Resident #1 A. Resident status Resident #1, age greater than…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-19 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required in a timely manner. Specifically, the facility failed to ensure residents received their showers as scheduled and incontinence care in a timely manner for residents dependent on staff for their care. Cross reference F677: failure to provide activities of daily living for dependent residents. Findings include: I. Facility policy and procedure The Staffing policy, revised 8/7/23, was provided by the nursing home administrator (NHA) on 3/19/25 at 2:21 p.m. It read in pertinent part, The facility maintains adequate staff on each shift to meet the residents' needs. The facility utilizes the facility assessment as the foundation to determine staffing levels necessary to ensure that residents' needs are met. II. Resident and family interviews Resident #1 was interviewed on 3/19/25 at 10:15 a.m. She said the facility did not have enough staff to care for her needs. She said when the facility was short staffed and had only two…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-27 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to provide a safe, functional and comfortable environment to meet resident needs in six of nine resident rooms. Specifically, the facility failed to: -Ensure resident room temperatures on the 100 unit resident hallway were between 71-81 degrees Fahrenheit. -Fix a broken furnace blower on the 100 unit hallway, which would have provided back up heat to the facility rooms when thermostats were below 71 degrees; and, -Ensure the resident's living room area on the 100 unit had heat between 71-81 degrees. Findings include: I. Facility policy and procedure The Keeping a Resident's Room in Order policy, revised 7/17/23, was provided by the director of nursing on 3/27/24 at 11:14 a.m. It revealed in pertinent part that the facility was to follow federal regulations and provide, Comfortable and safe temperature levels. Maintain a temperature range of 71 to 81°F. It is the responsibility of all staff to create a 'homelike' environment. Ensure the room…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · D2024-03-27 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure appropriate services and assistance to maintain or prevent further decrease in range of motion was provided for one (#1) of three residents out of seven sample residents. Specifically, the facility failed to: -Follow programs physical therapy (PT) and occupational therapy (OT) had written for restorative nursing to provide for Resident #1 who required range of motion (ROM) services; and, -Have trained staff provide consistent ROM for Resident #1 who needed the exercises to maintain his physical abilities or help to prevent further decrease in his ROM. Findings include: I. Facility policy and procedure The Restorative Nursing policy, revised 9/11/23, was provided by email by the director of nursing (DON) on 3/27/24 at 11:14 a.m. It revealed in pertinent part, To promote the resident's optimum function, a restorative program may be developed by proactively identifying, care planning and monitoring of a resident's assessments and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-14 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to ensure the medication error rate was less than five percent. Specifically, the facility had a medication error rate of 11.11%, which was three errors out of 27 opportunities for error. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-14 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews, the facility failed to ensure medications and biologics were stored and labeled properly on two of four medications carts and one of two medication storage rooms. Specifically, the facility failed to ensure: -Insulin (medication for diabetes) vials and pen injection devices were stored and labeled appropriately with open dates; -Ensure wound dressing supplies were not stored open next to medications in medication cart; -Ensure expired or discontinued medications were removed from medication carts and medication refrigerators; -Ensure medication that was stored in the refrigerator were stored at correct temperatures; -Ensure food were not stored in the medication refrigerators; and, -Ensure medication carts were kept locked. Findings include: I. Facility policy and procedure The Storage and Expiration Dating of Medications, Biologicals, revised on 8/7/23, received from the nursing home administrator (NHA) on 12/18/23 at 10:47 a.m. It revealed in pertinent part, facility should ensure that only authorized facility staff, as defined by facility,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-14 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to ensure glucometers were cleaned according to standards of practice. Findings include: I. Professional reference According to Infection Prevention during Blood Glucose Monitoring and Insulin Administration, retrieved on 12/27/23 from: https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html It revealed in pertinent part, Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. According to the Assure Prism Cleaning and Disinfecting the Assure Prism multi Blood Glucose Monitoring system retrieved on 12/27/23 from:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to obtain informed consent for the use of psychotropic medication for two (#62 and #134) of five residents reviewed for unnecessary medication of out 44 sample residents. Specifically, the facility failed to ensure informed consent which included reason for medication use, risks and benefits associated with use and any black box warning was obtained from the resident or resident representative prior to the resident's use of a psychotropic medication for Resident #62 and Resident #134. Findings include: I. Facility policy and procedure The Psychotropic Medication Use policy, revised on 10/24/22, was received by the nursing home administrator (NHA) on 12/18/23 at 11:30 a.m. It read in pertinent part: Facility staff should inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications. II. Resident #62 A. Resident status Resident #62, age [AGE], was admitted on [DATE].…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to honor resident choices for two (#66 and #134) of two out of 44 sample residents. Specifically, the facility failed to: -Provide a schedule for Resident #66 for rehabilitation services so he felt like he could leave his room, attend group activities and socialize with others; and, -Ensure Resident #134 and Resident #66 received bathing according to their preference. Findings include: I. Resident #66 status Resident #66, age [AGE], was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO), the diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (right sided weakness after a stroke), cognitive communication deficit, bipolar disorder, major depressive disorder and anxiety disorder. The 11/20/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. He had impairment on one side…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop an acute/baseline care plan for two (#139 and #134) of two reviewed for baseline care plans out of 44 sample residents. Specifically, the facility failed to ensure resident involvement in the development and provide a copy to Resident #139 and Resident #134. Findings include: I. Facility policy and procedure The Care Planning - Baseline, Comprehensive and Routine Updates policy and procedure, reviewed on 12/5/22, was provided by the nursing home administrator (NHA) on 12/18/23 at 9:30 a.m. It revealed in pertinent part, Completion and implementation of the baseline care plan with 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to ensure medications were dispensed according to professional standards of practice. Specifically, the facility failed to follow accepted standards of practice for medication administration by setting up three medications prior to administration. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice for one (#62) of one resident reviewed for pain out of 44 sample residents. Specifically, the facility failed to ensure parameters were in place for use of a scheduled topical pain medication for Resident #62. Findings include: I. Facility policy and procedure The Administration of Medications with a revision date 7/14/21, was received by the nursing home administrator (NHA) on 12/18/23 at 11:30 a.m. It read in pertinent part, A physician order that includes dosage, route, frequency, duration, and other required considerations including the purpose, diagnosis or indication for use is required for administration of medication. Any order that is incomplete, illegible or unclear, should be clarified II. Resident status Resident #62, age [AGE], was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO), the diagnoses included fracture of the T11 and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents who required dialysis received dialysis services consistent with professional standards of practice for one resident (#8) of one resident reviewed for dialysis out of 44 sample residents. Specifically, the facility failed to: -Ensure communication forms between the facility and the dialysis center were completed consistently and accurately for Resident #8; and, -Ensure bruit and thrill were assessed upon return from dialysis and not signed as completed prior to Resident #8 return. Findings include: I. Facility policy and procedure The Hemodialysis Off Site policy, reviewed on 8/23/23, received from the nursing home administrator (NHA) on 12/18/23 at 10:47 a.m. revealed in pertinent part the facility assures that each resident receives care and services for the provision of offsite hemodialysis dialysis consistent with professional standards of practice. Ongoing assessments of the residents condition and monitoring for complications…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to ensure one out of five nursing staff members were able to demonstrate skills and techniques necessary to care for residents' needs. Specifically, the facility failed to conduct an annual nursing competency for registered nurse (RN) #1. Cross-reference F658: the facility failed to ensure medications were not pre-poured prior to administration. Cross-reference F759: the facility failed to ensure it did not have a medication error rate above 5%. Cross-reference F760: the facility failed to ensure insulin was administered according to manufacturer guidelines. Cross-reference F880: the facility failed to ensure the glucometer was cleaned according to manufacturer guidelines and in between residents. Findings include: I. Record review The employee file for RN #1 was reviewed on 12/14/23 at 1:15 p.m. RN #1's employee file did not contain documentation that he had completed an annual competency to show he was able to demonstrate skills and techniques necessary to care for residents' needs since 2020. II. Staff interview The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews the facility failed to ensure residents were kept free of significant medication errors for one residents (#132) of eight reviewed for medication administration out of 44 sample residents. Specifically, the facility failed to ensure insulin (medications used for blood glucose regulation) vials containing one or more types of insulins were mixed prior to medication administration for Resident #132. Cross-reference F759 failure to ensure the medication error rate was less than five percent. Findings include: I. Professional reference According to the Humalog mix 75/25 insulin package insert retrieved on 12/21/23 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/021017s141s143lbl.pdf Dosage and administration Humalog 75/25 was a suspension that must be resuspended immediately before use. Resuspension was easier when the insulin had reached room temperatures. To resuspend the vial, carefully invert the vial at least 20 times until the suspension appears uniformly white and cloudy then inject immediately. II. Observations…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one resident (#14) of one reviewed for hospice services out of 44 sample residents. Specifically, the facility failed to ensure Resident #14's hospice agency care plan and notes were accessible to facility staff to coordinate care. Findings include: I. Facility policy and procedure The Hospice Coordination of Care policy and procedure, reviewed on 8/23/23, was provided by the nursing home administrator (NHA) on 12/18/23 at 10:47 a.m. revealed in pertinent part, facility provides hospice care under a written agreements and must ensure that each resident's written plan of care includes both the most recent hospice plan of care and description of the services furnished by the long term care facility to attain or maintain the residents highest practicable physical, mental, and psychosocial well being. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-11 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews and interviews, the facility failed to ensure residents were provided prompt efforts by the facility to follow up on grievances. Specifically, the facility failed to file and follow up on resident grievances related to staffing and call lights. Finding include: I. Facility policy The Grievance Program policy, dated 9/25/23, was received from the nursing home administrator (NHA) on 10/11/23 at 12:15 p.m. The policy read in pertinent part, Residents and their families have the right to file a complaint without fear of reprisal. Upon request, the facility must give a copy for the grievance policy to the resident. The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those who respect to care and treat which has been furnished as well as that which has not been furnished, the behavior of other residents, and other concerns regarding their facility stay. The resident has the right to, and the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and record review, the facility failed to ensure two (#2 and #8) of five residents reviewed for assistance with activities of daily living (ADL) out of 14 sample residents. Specifically the facility failed to ensure: -Resident #2 received timely incontinence care; and, -Resident #8 received her scheduled showers. Findings include: I. Facility policy and procedure The Activities of daily living (ADL) policy revised on 8/23/23, was received on 10/11/23 at 3:10 p.m. by the nursing home administrator. The policy read in pertinent part, The resident will receive assistance as needed to complete activities of daily living. Any change in the ability to perform ADLs will be documented and reported to the licensed nurse. Based on comprehensive assessment of a resident and consistent with the residents news and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-09-02 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that before a resident was allowed to self-administer medications, the interdisciplinary team (IDT) performed an assessment to determine if the resident could safely and reliably do so for one (Resident #64) of one sampled resident reviewed for self-administration of medications. Findings included: Review of a facility policy titled, Self-Administration of Medications, revised 01/2022, revealed the procedure for self-administration of medications included the following: - 2. Facility, in conjunction with the Interdisciplinary Care Team, should assess and determine, with respect to each resident, whether Self-Administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition. - 5. Facility should ensure that orders for Self-Administration list the specific medication(s) the resident may self-administer. - 7. Facility staff should monitor the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-09-02 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and facility policy review, the facility failed to ensure an allegation of abuse was reported to the Administrator for one (Resident #181) of two sampled residents reviewed for abuse. Findings included: Review of a facility policy titled, Protection of Residents: Reducing the Threat of Abuse & [and] Neglect, dated as reviewed 04/15/2019, revealed, Reporting and Response - All personnel will promptly report any incident or suspected incident of resident abuse and/or neglect, including injuries of unknown origin. The policy also indicated, All alleged or suspected violations involving mistreatment, abuse, neglect, injuries of unknown origin (e.g. [for example], bruising and skin tears) will be immediately reported to the administrator and/or director of nursing. Review of an admission Record revealed Resident #181 was admitted to the facility with diagnoses of congestive heart failure and pleural effusion. Review of Progress Notes, dated 06/19/2022 at 9:00 AM and electronically signed by Registered Nurse (RN) #1, revealed a family member indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-09-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident received non-pressure-related wound treatment/care in accordance with physician's orders for one (Resident #40) of two sampled residents reviewed for wound care. Findings included: Review of a facility policy titled, Treatment Orders, revised 04/19/2022, revealed, Policy: Treatment orders are written per physician orders. The policy also indicated, Procedure.1. After observation/evaluation of the affected skin area, the physician is notified. 2. As appropriate, the physician writes a treatment order that includes at least the following. Site of wound. Name of cleanser. Name of ointment (medicated or non-medicated). Type of dressing. Number of times to perform the treatment/duration of treatment. 3. The physician order is followed, as are the manufacturer's instructions for use of each product ordered. Review of an admission Record revealed the facility readmitted the resident after a hospital…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to LIFE CARE CENTERS OF AMERICA — 194 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.4 | +0.6 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 193 homes this chain runs (chain average 3.4★, per CMS)
Showing 40 of 193; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| STRONG, JESSICA | Individual | W-2 MANAGING EMPLOYEE | since 11/29/2021 |
| CROSS, CINDY | Individual | CORPORATE OFFICER | since 02/03/1994 |
| THURMOND, JOAN | Individual | CORPORATE OFFICER | since 09/21/2000 |
| LIFE CARE CENTERS OF AMERICA, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 09/08/1983 |
| DEVELOPERS INVESTMENT COMPANY INC | Organization | GENERAL PARTNERSHIP INTEREST | since 07/06/1983 |
| PRESTON, FORREST | Individual | LIMITED PARTNERSHIP INTEREST | since 07/06/1983 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.3M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CO
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Colorado Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 065092. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
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